
<script type="text/javascript" src="{path}"></script>
<form name="form_reg" id="form_reg">
<tr><td class="content_wrapper1_td">	
	<table cellpadding="0" cellspacing="0" border="0">
      <tbody>
      
		
		</tbody></table><table border="0" width="100%" cellspacing="0" cellpadding="2">
          <tbody><tr>
            <td class="main indent_2"><b>Dados Pessoais</b></td>
           <td class="inputRequirement" align="right">&nbsp;</td>
          </tr>
        </tbody></table>
				

 	<table cellpadding="0" cellspacing="0" border="0" align="center" class="infoBox_">
		<tbody><tr>
		  <td class="infoBox__">
			<table border="0" cellspacing="4" cellpadding="2">
              <tbody>
              <tr>
                <td class="main b_width"><strong> Nome:</strong></td>
                <td class="main width2_100"><input type="text" name="firstname" >&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Sobre Nome:</strong></td>
                <td class="main width2_100"><input type="text" name="lastname">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Data de Nascimento:</strong></td>
                <td class="main width2_100"><input type="text" name="dob">&nbsp;</td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Email:</strong></td>
                <td class="main width2_100"><input type="text" name="email_address">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
            </tbody></table>

</td></tr>
	</tbody></table>		

	
<div style="padding:0px 0px 0px 0px;"><img src="./AAAAAAAAAAAAAAAAAAAAA_files/spacer.gif" border="0" alt="" width="1" height="1"></div>
    <table cellpadding="0" cellspacing="0" border="0">
	  <tbody><tr>
        <td class="main indent_2"><b>Endere&ccedil;o</b></td>
      </tr>
	</tbody></table>
				

 	<table cellpadding="0" cellspacing="0" border="0" align="center" class="infoBox_">
		<tbody><tr><td class="infoBox__">
			<table border="0" cellspacing="4" cellpadding="2">
              <tbody><tr>
                <td class="main b_width"><strong>Rua/Av:</strong></td>
                <td class="main width2_100"><input type="text" name="street_address">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Numero:</strong></td>
                <td class="main width2_100"><input type="text" name="nrc">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Bairro:</strong></td>
                <td class="main width2_100"><input type="text" name="suburb">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>CEP:</strong></td>
                <td class="main width2_100"><input type="text" name="postcode">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Cidade:</strong></td>
                <td class="main width2_100"><input type="text" name="city">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                 <td class="main b_width"><strong>Comp:</strong></td>
                <td class="main width2_100"><input name="comp" type="text" id="comp" value="{comp}" />                  <span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>UF:</strong></td>
                <td class="main width2_100">
<input name="state" type="text" maxlength="2">&nbsp;<span class="inputRequirement">*                </span></td>
              </tr>
             
            </tbody></table>
				
</td></tr>
	</tbody></table>
<div style="padding:0px 0px 0px 0px;"><img src="./AAAAAAAAAAAAAAAAAAAAA_files/spacer.gif" border="0" alt="" width="1" height="1"></div>
	<table cellpadding="0" cellspacing="0" border="0">
      <tbody><tr>
        <td class="main indent_2"><b>Contato</b></td>
      </tr>
	</tbody></table>
					

 	<table cellpadding="0" cellspacing="0" border="0" align="center" class="infoBox_">
		<tbody><tr><td class="infoBox__">
			<table border="0" cellspacing="4" cellpadding="2">
              <tbody><tr>
                <td class="main b_width"><strong>Residencial:</strong></td>
                <td class="main width2_100"><input type="text" name="telephone">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Celular:</strong></td>
                <td class="main width2_100"><input type="text" name="fax">&nbsp;</td>
              </tr>
            </tbody></table>
				
</td></tr>
	</tbody></table>

<div style="padding:0px 0px 0px 0px;"><img src="./AAAAAAAAAAAAAAAAAAAAA_files/spacer.gif" border="0" alt="" width="1" height="1"></div>
	<table cellpadding="0" cellspacing="0" border="0">
      <tbody><tr>
        <td class="main indent_2"><b>Acesso</b></td>
      </tr>
	</tbody></table>
					

 	<table cellpadding="0" cellspacing="0" border="0" align="center" class="infoBox_">
		<tbody><tr><td class="infoBox__">
			<table border="0" cellspacing="4" cellpadding="2">
              <tbody>
              <tr>
                <td class="main b_width"><strong>Usu&aacute;rio:</strong></td>
                <td class="main width2_100"><input type="password" name="login" maxlength="40" id="login">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              <tr>
                <td class="main b_width"><strong>Senha:</strong></td>
                <td class="main width2_100"><input type="password" name="password" maxlength="40">&nbsp;<span class="inputRequirement">*</span></td>
              </tr>
              
              
              <tr>
                <td height="20" class="main b_width" colspan="2"><strong><span id="error" class="inputRequirement"></span></strong></td>
                
              </tr>
              
            </tbody></table>
				
</td></tr>
	</tbody></table>
<div style="padding:0px 0px 0px 0px;"><img src="./AAAAAAAAAAAAAAAAAAAAA_files/spacer.gif" border="0" alt="" width="1" height="1"></div>				
<table cellpadding="0" cellspacing="5" border="0"><tbody><tr><td>
			<table border="0" width="100%" cellspacing="0" cellpadding="2">
				<tbody><tr><td>
                	<a href="#" style="text-decoration:none;color:#000" onclick="envia_dados('form_reg')">
                    	<img src="imagens/reg.png" border="0" alt="Continue" title=" Continue ">&nbsp;<b>Registrar</b></a>
                &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                	<a href="#" style="text-decoration:none;color:#000" onclick="carregaBusca('modulo/carrega_autenticador/ctrl.CarregaAutenticador.php?jquery=1','telas')">
                    	<img src="images/voltar.gif" border="0" alt="Continue" title=" Continue ">&nbsp;<b>Voltar</b></a>
                </td></tr>
            </tbody></table>
				
</td></tr></tbody></table>	
</td></tr>
</form>